4. Lupus erythematosus: chronic inflammatory disease of connective tissue; may affect or involve any organ; vague etiology, but genetic factors, viruses, hormones, and drugs are being investigated; occurs primarily in women ages 18-35 yr. Two forms: discoid lupus erythematosus (DLE) affects skin only, and systemic lupus erythematosus (SLE) affects multiple organs.
1. Pathophysiology: possible toxic effects from immune complexes deposited in tissue (antibodyantigen trapping in organ capillaries) - fibrinoid necrosis of collagen in connective issue, small arterial walls (kidneys and heart particularly) cellular death, obstructed blood flow.
2. Assessment:
   1. Subjective data:
      1. Pain: joints.
      2. Anorexia; weight loss.
      3. Photophobia; sensitivity to sun.
      4. Weakness.
      5. Nausea, vomiting.
   2. Objective data:
      1. Fever.
      2. Rash: butterfly distribution across nose, cheeks.
      3. Lesions: raised, red, scaling plaques - coinlike (discoid).
      4. Ulceration: oral or nasopharyngeal.
      5. Lab data:
         1. Blood: increased LE cells; decreased - RBCs, WBCs, thrombocytes.
         2. Urine - hematuria, proteinuria (nephritis).
3. Analysis/nursing diagnosis:
   1. Risk for injury related to possible autoimmune disorder.
   2. Pain related to joint inflammation.
   3. Risk for activity intolerance related to extreme fatigue, anemia.
   4. Body image disturbance related to chronic skin eruptions.
   5. Altered nutrition, less than body requirements, related to anorexia, nausea, vomiting.
   6. Altered oral mucous membrane related to ulcerations.
4. Nursing care plan/implementation:
   1. Goal: minimize or limit immune response and complications.
      1. Activity: rest; 8 - 10 hr sleep; unhurried environment; assist with stressful activities; ROM to prevent joint immobility and stiffness.
      2. Skin care: hygiene; topical steroid cream as ordered for inflammation, pruritus, scaling.
      3. Mouth care: several times daily if stomatitis present; soft, bland, or liquid diet to prevent irritation.
      4. Diet: low sodium if edematous; low protein with renal involvement.
      5. Observe for signs of complications:
         1. Cardiac/respiratory (tachycardia, tachypnea, dyspnea, orthopnea).
         2. GI (diarrhea, abdominal pain, distention).
         3. Renal (increased weight, oliguria, decreased specific gravity).
         4. Neurological (ptosis, ataxia).
         5. Hematological (malaise, weakness, chills, epistaxis); report immediately.
      6. Medications, as ordered:
         1. Analgesics.
         2. Anti-inflammatory agents (aspirin, prednisone) and immunosuppressive drugs (azathioprine [Imuran], cyclophosphamide [Cytoxan]) to control inflammation.
         3. Antimalarials for skin and joint manifestations.
   2. Goal: health teaching.
      1. Disease process: diagnosis, prognosis, effects of treatment.
      2. Avoid precipitating factors:
         1. Sun (aggravates skin lesions; thus, cover body as much as possible).
         2. Altering dosage of medications.
         3. Pregnancy requires medical clearance.
         4. Fatigue, stress.
         5. Infections.
      3. Medications: side effects of immunosuppressives and corticosteroids.
      4. Regular exercise: walking, swimming; but avoid fatigue.
      5. Wear Medic Alert bracelet.
5. Evaluation/outcome criteria:
1. Attains a state of remission.
2. No organ involvement (e.g., cardiac, renal complications).
3. Keeps active within limitations.
4. Continues follow-up medical care - recognizes symptoms requiring immediate attention.